Tuesday, January 27, 2015

ICD-10 Codes in Non-Claim HIPAA Transactions

Most everyone involved with ICD-10 knows that the HIPAA 837 Healthcare Claims Transactions (Professional, Institutional & Dental) contain ICD-10 diagnosis and procedure codes and, therefore, must be considered when making their systems and processes ICD-10 compliant. But what other HIPAA transactions contain ICD-10 diagnosis and procedure codes?

Based on the amount of information shared on the web and some cursory research I’ve performed looking for information and guidance on non-claim HIPAA transactions impacted by ICD-10, it appears that not many people are aware that there are other HIPAA transactions that can also contain ICD-10 codes.

1. Diagnosis Codes and a Diagnosis Code Qualifier for each code2. Procedure Codes and a Procedure Code Qualifier for each code

Benefit Enrollment and Maintenance (834)

This transaction includes Diagnosis Codes and a Diagnosis Code Qualifier for each code.

Healthcare Services Review – Request for Review and Response (278)

1. Diagnosis Codes and a Diagnosis Code Qualifier for each code.

2. Procedure Codes and a Procedure Code Qualifier for each code.3. Surgical Procedure Codes and a Surgical Procedure Code Qualifier for each code.

But We’ve Already Addressed this via our 5010 Upgrade!

Just because your organization is 5010 compliant doesn’t necessarily mean you’re out of the woods with your HIPAA transactions when it comes to ICD-10. Most 5010 upgrades merely tested the format of 5010 transactions and their ability to carry ICD-10 codes and qualifiers. Little, if any, focus was likley given to making sure ICD-10 procedure and ICD-10 diagnosis codes were correctly assigned to the transactions and that the transactions were correctly processed in applications: front-end or downstream.

And it seems unlikely many organizations got into testing various processing scenarios.

Special Processing Scenarios. Like What?

There are some special processing scenarios organizations may want to consider when addressing the 278 Healthcare Services Review transactions. For instance,

What is the appropriate response to a 278 referral inquiry if the inquiry is submitted after 10/1/2015 but the original referral request was submitted prior to 10/1/2015? Is it ok to respond with a transaction containing ICD-9 codes? Will the transaction even pass any transaction compliance checks performed by your EDI tools or clearinghouse?

What about a request for a referral extension? Referrals submitted prior to 10/1/2015 will contain ICD-9 codes and would typically be valid for up to a year. If a referral request extension is submitted on 10/2/2015, which ICD code set should be used?

I’m sure there are other considerations.

It’s Imperative!

As WEDI states in the document I noted above: “it is imperative that we have a clear understanding of where the ICD-10-CM and ICD-10-PCS codes are used in the transactions required under HIPAA and used in the health care industry to exchange diagnosis and procedure information.